2009 Christmas Programs Application

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2017 DELTASSIST CHRISTMAS PROGRAMS APPLICATION

Last Name: First Name: ______Age:

Tel: Cell: ______Email: ______

Address: Ladner, Tsa, ND _____ Postal Code:

Additional Delivery Information – e.g.: Apartment name, basement, left side, back door, main door… ______

Contact Person (if we are unable to reach you – very important):

Name: Tel:

OTHER ADULTS LIVING WITH YOU (who are also contributing to the household income):

Last Name First Name Age Sex

CHILDREN (16 years old and younger who live with you and you have custody of):

OTHER ADULTS LIVING WITH YOU (family members who are dependent on you):

PLEASE TURN OVER… HAMPER:

1. I would like my family to receive a Christmas Food Hamper: YES NO

If yes: 2. We would like a regular hamper: with turkey without turkey OR a vegetarian Hamper

TOY DEPOT:

3. I would like to attend the Toy Depot: YES NO

4. Please choose a 1st, 2nd, and 3rd best time to attend the toy depot. Mark with a 1, 2, & 3

Tuesday, Dec 12: 10:00am – 12:00pm 1:00pm – 4:00pm 5:00pm – 8:00pm

Wednesday, Dec 13: 10:00am – 12:00pm 1:00pm – 4:00pm 5:00pm – 8:00pm

Thursday, Dec 14: 9:00am – 1:00pm

5. Will you be arriving by car or bus? CAR BUS

INCOME (please check any that apply):

6. E.I. Income Assistance CPP OAS Disability Employed

Other :

All information provided by me will be kept in confidence with the exception of the following:

I declare that everything on this application is correct and that Deltassist may contact any of the above to confirm my source of income. I understand that if it cannot be verified I may be disqualified for help from the Deltassist Christmas programs. If my family is chosen for a sponsored hamper, I will be contacted with the pick up date and time. I will not be applying elsewhere for a hamper.

Signed: Date:

NOTE: Applications must be made in person between 9:30 AM – 4:00 PM, Monday - Friday Please bring this completed form with you to one of the Deltassist offices: 9097 - 120th Street, North Delta or #202 – 5000 Bridge Street, Ladner. (Ladner office is closed 12 – 1 pm)

Keep the information page for your reference.

BE SURE TO BRING WITH YOU: 1) Proof of Address (eg. recent phone or hydro bill, official rent receipt or rental agreement) 2) Proof of Income for all adults in household (eg. 2 recent cheque stubs or pay slips) 3) Care Cards for each child on the application

APPLICATION DEADLINES: Toy Depot – December 8th, 2017 Food Hamper – December 15th, 2017

For Office Use Only:

Date application received: Staff/Volunteer Name:

Confirmation that client has shown proof of: Income Care Card Residence